Tuesday, February 2, 2010

I am involved in a case right now that epitomizes all that is wrong with commercial health insurance. All in one case. How convenient.

My patient is a young adult with a sarcoma diagnosed in her liver. There is one large mass and several smaller ones. The tumor is not resectable right now, so she will need chemotherapy.

Two issues have arisen this week: one related to diagnostic imaging (radiology) and the other related to quality of life. With both issues I have faced significant roadblocks, placed by the patient's insurance company, that impede my ability to provide the care this young woman needs.

I'll start with the imaging issue. The patient's sarcoma is not one that typically arises in the liver. Also, the presence of multiple masses is more consistent with spread TO the liver, rather than the tumor arising FROM the liver. That means, if we hope to cure this young woman, we need to find the primary tumor. A CT scan of her chest, abdomen, and pelvis showed nothing. An MRI of her pelvis, to better evaluate her uterus, a place that this tumor could arise, showed nothing. Because a tumor like she has can come from anywhere in the body, I ordered a PET scan. The insurance company denied coverage.

Why?

Because, the physician reviewer told me, there is no evidence that a PET scan is useful in this disease.

Of course, the physician reviewer is not an oncologist, and therefore not a sarcoma specialist, so I'm sure he does not keep up with the latest literature about PET scans and sarcomas. But I do. A quick search of PubMed using the terms "sarcoma" and "PET" revealed 471 articles. I faxed him 4 of them yesterday. I hope that is sufficient evidence to allow me to get the test I, the treating physician, believe my patient needs in order to maximize my chance of curing her. I'll find out later today or tomorrow.

The other roadblock involves her quality of life. My patient will need a chemotherapy drug called ifosfamide to treat her tumor. This drug has a significant risk of infertility associated with it. After consultation with a reproductive endocrinologist, we decided that the best was to try to protect her fertility would be to use a drug called Lupron. Unfortunately, Lupron is expensive, so it requires prior authorization from the insurance company. I just received an email from our clinic coordinator that read, in part, "It won’t be covered if it’s for fertility reason (per her case manager)."

So... I have some choices to make. Do I lie and say the drug is being prescribed for another indication? Do I tell the truth and risk the family having to pay $750 per dose out of their own pockets? Or do I choose a different drug, one that will not work as well, and know that I am not providing optimal care for this young woman, and am increasing her risk of infertility?

All because her health insurance company wants to save a few bucks. At least they are "not for profit." Imagine the difficulties we face when the insurance company is trying to provide dividends for their investors, instead of health care for their customers.

35 comments:

This issue merits several rants. It makes my blood boil. Your patients deserve access to every option you deem reasonable to preserve their quality of life while you work hard to cure their disease. How dare some uninvolved, uninformed non-oncologist at an insurance company override your judgment! I still think about an earlier blog where you wondered why an insurance physician was allowed to essentially treat a patient s/he had never even seen. This is wrong, wrong, wrong.

As an aspiring doctor looking into medicine I find you stuff interesting.

Insurance companies and their abilities to influence decisions (amongst other issue) has been a huge concern of mine.

Being a doctor is no easy task and all the school you go through allows gives certain rewards." Like the ability for the doctor to be able to make the best decision for/with patients. It seems like a loosing battle.

One of many (like your patient with cancer tells me other wise). One refuting argument that doctors usually hire someone to "argue" or "negotiate" with insurance companies. Whether they are the receptionist or some 3rd party.

Maybe you could weigh in on that and why you have to speak to the insurance company. Is it because of confidentiality? Or maybe no one can speak on a physicians behalf for liability?

It's sad that ins. companies pretend all the new studies that point to PET scan's usefulness in sarcoma care (and really, most other cancers) don't exist.

I was pretty shocked when I read through my insurance company's clinical policy fine print how limited they were about covering PET scans (without a fight, well, less of a fight). I think the list included less than 10 cancers.

I would have sent him the 471 titles, authors and abstracts along with the four articles. How could he argue with it? What I don't get is why, after one patient ends up getting approval with a certain insurance company, why does the next patient with the same insurance company have to start over again being turned down for the same procedure that has been already approved for the previous patient. I'm talking about with the same diagnosis and situation. Also, have a question regarding the fertility issue. Is there a way her eggs could be harvested and kept until after treatment?

Thanks for posting Dr. David. As the parent of a child with a chronic health condition, this is one of my most-frequent rants: "Who gave the insurance company the right to diagnose and practice medicine?" I use it - quite loudly - in the line waiting to speak to the pharmacist, at the doctor's office, etc.

There's something wrong when a patient is denied treatment by someone(s) not competent to make those decisions - or denied a prescription refill because its "too early" and the patient is going out of town.

As the clinic coordinator in this case, this is not the first or the last time I will encounter something of the nature. All too often insurance companies put the bottom line well before patient care. Why do physician have to charge a high rate for service? They have to pay for me! On a daily basis, I have at least 20 cases on my desk to try and convince an insurance company to approve treatment and/or medications that will improve the patients quality of life. This is distressing for the unfortunate loved ones who have to deal with the sometimes long wait. As if a child with cancer is not enough to deal with! When we talk about health care reform, we need to discuss how insurance companies come to their conclusions without the appropriate education to back these decisions placing the patient as great risk. Guidelines putting the patient interest first need to be be set. My dream is to become unemployed for either a cure for pediatric cancers or that there will be no need to fight insurance companies to get the necessary medications and treatments these children deserve.

About fertility: Why don't you ask a gynecologist to laparoscopically harvest some ovarian cortex for freezing? In literature, there has been reports for even having a spontaneous pregnancy after replanting the tissue to the pelvis near ovaries - assuming she survives. Of course, it is experimental, but used as a praxis f.e. with young female lymphoma patients here in Finland where I live.

And luckily, we don't have similar problems with insurance companies! We get to do what we need to do, for every patient. (But we don't do everything with everybody, only when reasonably).

Thanks to everyone for their comments. Somehow, I knew this would generate some response.

Elizabeth and Gyn Onc both asked about fertility preservation. The reproductive endocrinologist we work with (whose particular interest is treating women with cancer) has frozen away segments of ovary on other patients like this in the past. Unfortunately, for this patient that was not an option. Even if it was, it falls under the category of "experimental" and is even harder to get approval for than a PET scan.

It is amazing how much we as healthcare providers are controlled by the third payor parties rather than actual science of medicine. Fighting the insurance companies for the sake of patients takes up time that could be better utilized for caring of patients. I wish we had a good solution to a problem recognized by most.

I came across your blog while looking up similar interests to what I plan on doing when I am an adult. I am in a program at my school which allows me to shadow a doctor in the field I choose. I have always been very fond of pediatric oncology, so your blog was perfect for me to find. I was wondering what pointers you could give me as I embark on my journey into the medical field.

Thanks for writing about this from a doctor's point of view, Doctor David. It's a really frustrating area for many of us, especially since there are really very limited places for patients to turn if they're denied. I've been following the Nehme case in California on my blog (http://myhealthcafe.wordpress.com). Anthem Blue Cross denied a patient's request to have a liver transplant in Indianapolis, instead of potentially dyihg on the waiting list at UCLA.

If it's at all useful to your patients, my blog and website (MyHealthCafe.com) provide information to patients to help them navigate their health insurance and government programs to pay for their healthcare. It's our attempt to help people get through the system a little easier.

I am an aspiring pediatric oncologist and insurance issues make my blood boil.Who are non-physicians to tell you what is and what is not experimental? If only money could be pushed aside for a moment, and they could be put in the patient's place.I wonder when this world will wake and see the important things in life, such as this. Quality of life should not be given a price tag.

Insurance companies and their abilities to influence decisions (amongst other issue) has been a huge concern of mine. I still think about an earlier blog where you wondered why an insurance physician was allowed to essentially treat a patient s/he had never even seen.

I recently moved to Chicago from India, and have had to deal with health insurance policies, both as a customer and a future therapist. I have to say, I am pretty ignorant about the coverages and in fact, the need itself, for health insurance. I know that medical care in America is very expensive and an average Joe can not afford it, but does health insurance cover medications and treatments that one would really need it for?

The lady in your case, for example, is not being helped by insurance. So I am wondering, who benefits? I have heard of a lot of cases where people have had to pay out of their pockets because their insurance does not cover what they needed. The other side of the story is that a lot of insurance companies don't reimburse therapists (I don't know how it works for medical doctors.)

I have completely drifted off the topic! I just wanted to say that I have a visceral reaction to your dilemma. I'd like to know though, did you hear back from the physian after sending him the studies about PET and Sarcoma?

Your a doctor. You took an oath. Your loyalty here is to your PATIENT; NOT your patients insurance company. You have no relationship or responsibility to them. They represent money. You represent your patient. You do WHATEVER you have to do in order to get, what YOU believe, is the best care possible for YOUR particular patient. Whatever that may be. And if you do this; you will sleep GREAT at night. Period. I sincerely hope that helps. Good luck to you and your patient.

I agree with the post that most of the insurance companies save money because if their betterment. In fact, they have to keep in mind that their main aim should facilitate the patients. So they can make proper treatment.

I am sure a for profit insurance company would just let the patient die in the street and pocket the money. The better solution would be to let the government take over healthcare that way you would just be put on a waiting list for months or years like in Canada or Brittan. Most likely the life saving drugs would have never even been invented at all. Not to worry the new Affordable Care Act is here to save the day and those pesky insurance companies will soon all be out of business and we won’t have to worry about them anymore.

I know the time has now passed, but could you claim the Lupron is for medical reasons: the chemotherapy treatment could cause her to have very low platelets. Having periods with no platelets is not good... Lupron is a safe and effective way to ensure she has no periods for the duration of her treatment. Would that work, since it doesn't bring fertility into it?

The whole insurance issue really puts me off ever living in America. I honestly don't think I could practise medicine in a country where everything is so financially driven for patient care. I'd be permanently frustrated.

Many insurance companies are offering polices with variety of covers; therefore, selection of trusted and reliable company is bit difficult. In this connection, you can get information from your friends, who already have purchased the same insurance policy. Moreover, you can also consult a trusted insurance agent of your area for the selection of reliable Insurance Company in Houston

Some insurance companies will do anything to save money by denying a claim or coverage. If you're in need of health insurance, life insurance, car insurance, or home insurance in Leominster MA, I highly recommend Foster Insurance. I always have had a good experience with them. Check out their site to learn more about the company and their policies.Btw, did you hear back from the physician after sending him the studies about PET and Sarcoma? I hope everything works out for this young lady.

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